Lion Air Flight

There is much speculation as to the cause of the Lion Air Flight JT610 crash on October 29 that killed 189 people. 

Soon after the “black box” of the Boeing 737 Max aircraft was recovered, people were speculating that a design flaw caused the accident. Boeing stock fell and one of the victims’ family even initiated a lawsuit accusing Boeing of failing to inform the pilots of the new anti-stalling feature on its 737 Max. The discussion/debate on the anti-stalling system (known as MCAS) is still ongoing. Reports in the last two days have even surfaced that Lion Air is considering cutting its order of Boeing 737 Max aircraft.

Then the focus shifted to maintenance.

The BBC reported that the aircraft maintenance records showed that six problems had been identified on the plane since October 26 including errors with its airspeed and altitude information displays. The article goes on to report that the aircraft’s AOA sensor had encountered problems and was replaced the day before the crash.

I’m not here to judge or take a wild guess as to what happened. There are many in the mainstream media who are more than willing to prematurely “determine” what happened. Let’s just wait for the investigation to conclude and learn from it.

After all, none of us are perfect. We all make mistakes. The important thing is to learn from our mistakes and not make them again.

When it comes to accidents and incidents, rarely is the cause simply “mechanical failure.” The “Dirty Dozen” are human factors that often lead to accidents and incidents. As a recap, they are:

  • Fatigue
  • Stress
  • Complacency
  • Lack of Communication
  • Lack of Awareness 
  • Distraction
  • Lack of knowledge
  • Teamwork
  • Lack of Resources 
  • Pressure
  • Lack of Assertiveness
  • Norms

These are all preconditions to unsafe acts. D.O.M .magazine contributing writer Gordon Dupont, known as the father of the Dirty Dozen, has shared articles on each of these human factors with us over the past several years. Not only does he describe each of these factors and how they can affect safety, he provides safety nets that we can put in place to prevent them from leading to an incident or accident. (Just in case you don’t have back copies of all our magazines available, you can always browse our past issues on

We have serious responsibilities as aircraft maintenance professionals. As mechanics, we need to ensure we are doing everything we can to ensure safety and airworthiness. As managers, we need to ensure our staff has the resources, training and knowledge to do their jobs safely. We often work under tight deadlines — it’s part of the job. We just can’t allow pressure or deadlines to influence our commitment to safety! 

Here’s to a safe and prosperous New Year!

Thanks for reading, and we appreciate your feedback!






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D.O.M. magazine is the premier magazine for aviation maintenance management professionals. Its management-focused editorial provides information maintenance managers need and want including business best practices, professional development, regulatory, quality management, legal issues and more. The digital version of D.O.M. magazine is available for free on all devices (iOS, Android, and Amazon Kindle).

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